When a loved one is in hospital, arranging their care can feel stressful. Getting them home safely is important, but the discharge process can be confusing. This guide explains what to expect and how Live in Solutions can help make the transition smooth and secure.
What happens at discharge?
Hospital discharge teams manage a patient’s safe transfer of care, with the aim of getting people home once they are medically fit. Hospitals focus on treatment and recovery, while longer term support and assessments continue outside the ward.
How needs are assessed
Hospitals use the national Discharge to Assess (D2A) framework. A multi-disciplinary D2A team, which may include doctors, nurses, occupational therapists and social workers, will assess needs and place the person into one of four pathways:
- Pathway 0: Medically fit, no extra support needed.
- Pathway 1: Short-term support at home, such as therapy or visiting carers.
- Pathway 2: Temporary residential care while longer term plans are made.
- Pathway 3: Ongoing nursing care in a facility.
A senior clinician must sign the patient off as medically fit and a written care plan should be provided before discharge.
What to do if you disagree with a discharge decision
If you think the discharge is unsafe or the assessment was incomplete, raise this with hospital staff straight away. You can also contact the Patient Advice and Liaison Service (PALS) for confidential support and guidance on next steps.
Free and funded care after hospital
Many people benefit from short-term reabblement, or intermediate care funded by the NHS to support recovery at home. This can last for a few weeks and, if needed, up to six weeks of free care may be provided to help rebuild independence.
If longer term support is required after that period, the local authority will complete a fresh assessment to determine eligibility for social care funding.
How Live in Solutions supports discharges and recovery
Live in Solutions specialises in bespoke live-in-care that helps people recover safely at home. We can support the discharge process in several practical ways:
- Fast, personalised assessments. We can conduct a rapid needs review and suggest appropriate live-in-care options.
- Liaison with medical teams. We communicate with hospital discharge teams, therapists and families so care plans are joined up.
- Short-term reablement support. Our carers provide focused, practical help to rebuild strength and daily living skills.
- Ongoing live in care. If someone needs continuous support, we can arrange a matched live in carer to provide one-to-one help in familiar surroundings.
- Practical help at home. Our carers can assist with mobility, medication reminders, meal prep, light housekeeping and support with follow-up appointments.
- Guidance on funding. We can explain the difference between NHS-funded reablement and local authority assessments, and support families to explore direct payments if eligible.
Practical tips for a smoother discharge
- Prepare questions. Ask about medication, follow-up appointments and the written care plan.
- Get the care plan in writing. Keep the plan for reference and share it with anyone involved in day-to-day care.
- Check funding routes. Ask about NHS reablement and whether a local authority assessment is needed later.
- Make the home safe. Declutter paths, consider grab rails and ensure basic supplies are on hand.
- Arrange transport. Organise someone to collect your loved one or ask if the hospital can arrange non-emergency transport.
Ready to talk?
If your loved one needs support after a hospital admission, Live in Solutions can help with a free, no-obligation assessment. We match trained carers to each person’s needs, and we work with families and clinical teams to make discharge and recovery safer and less stressful.
Call our friendly team in confidence on 01245 890 336 or message us to arrange a free assessment.